Finding the “sweet spot” in clinical evidence

HIM program leaders should work with physicians to outline clinical indicators and definitions for “controversial” diagnoses. These departments must ensure that any such information is part of ongoing coding and physician education and that it gets updated annually or at least as frequently as advances in regulations or healthcare standards demand. Although such efforts provide guidance to all parties, physicians can still determine a diagnosis based on his or her clinical judgment.

For example, when a patient presents with pneumonia, one of the clinical indicators would be an infiltrate on the chest x-ray. However, if the patient is severely dehydrated, the x-ray may not show an infiltrate. Similarly, if the patient is presenting with an acute exacerbation of congestive heart failure in addition to pneumonia, infiltrates may not be visible. In both of these examples, physicians can use their clinical judgment and assign a pneumonia diagnosis and treat accordingly.

Unfortunately, there is no exact answer when determining how much clinical evidence to include in a query. The key is finding the “sweet spot” wherein there is enough evidence to support a given diagnosis without overwhelming the reader.

Clinical evidence should generally include information from some or all of the following areas:

• Sign and symptoms with duration

• Diagnostic test results

• Lab findings

• Findings of consultants

• Treatment performed

For example, when writing a query for pneumonia, the following information should be included: 

• Signs and symptoms: Fever 101°, green sputum, cough for a week

• Diagnostic test results: Chest x-ray with left lower lobe infiltrate

• Lab findings: White blood cell count of 14,000

• Treatment: Started on Levaquin intravenous (IV) piggyback

Notice that this example did not include multiple sets of vital signs, as the diagnosis of pneumonia is made primarily based on signs and symptoms and radiological findings. Some diagnoses are less straightforward and require more clinical evidence to write a compliant query.

For example, when writing a query for a suspected case of acute renal failure, more in-depth information may be needed, with the treatment and outcome tied together, such as the following:  

• Signs and symptoms: Severe nausea and vomiting for one week and unable to keep down fluids. History of normal creatinine values prior to admission.

• Lab findings: Creatinine 3.6 at admission and decreased to 1.2 after 24 hours of IV fluid boluses.

• Findings of consultants: The nephrologist states “renal failure.”

Those new to the coding profession often struggle to determine the amount and type of clinical evidence to include with a query. Coding Clinic for ICD-10-CM/PCS states that such facility-specific policies can help provide instruction as to “when they should query physicians for clarification” (AHA, 2000, p. 12).

Even though Coding Clinic offers a variety of additional advice regarding when a clinical indicator (or lack thereof) may warrant the submission of a query, the 2019 AHIMA/ACDIS query practice brief Guidelines for Achieving a Compliant Query Practice warns that Coding Clinic is neither an “authoritative” nor “comprehensive” resource for determining when queries may be appropriate (AHIMA/ACDIS, 2019).

The brief states that a query should be considered when “it appears a documented diagnosis is not clinically supported” (AHIMA/ACDIS, 2019, p. 3). CMS also provided guidance published in its July 2011 Medicare Quarterly Provider Compliance Newsletter. In it, CMS instructs coders to do the following: 

… refer to the Coding Clinic guidelines and query the physician when clinical validation is required. The practitioner does not have to use the criteria specifically outlined by Coding Clinic, but reasonable support within the health record for the diagnosis must be present (CMS, 2011). 

Again, there is no magic formula for the amount of information to include in a query. AHIMA’s 2008 guidance called “Managing an Effective Query Process” states the following:

Your [documentation] reviewer must use his or her professional judgment and discretion in considering the information contained on a hospital’s physician query form along with the rest of the medical record (AHIMA, 2008).

Ultimately, coders need to think strategically and consider what the receiver of the information needs in order to make a clinical decision, using objective information that illustrates the true clinical picture. In general, as long as the diagnosis and treatment are consistent throughout the documentation, a diagnosis should be assigned. Remember, by documenting a diagnosis, the physician is accepting legal accountability for it. Nevertheless, if there is conflicting documentation and/or treatment, the attending physician should be queried to determine whether the condition was ruled in or out.

Editor’s note: This article is an excerpt from “The Coder's Guide to Physician Queries, Second Edition” by Dr. Jillian Harrington, MHA, CPC, CPC-I, CPC-P, CCS, CCS-P, CEMC, MHP.